Germana, Mary TORN OF QUEEVBU9KY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK I2804
(518) 745-4476 (518) 745-4477
Funeral Director AA K,
N am e �� 1� GL�(L-�✓1/"� IV -' Case#
Date Of Cremation --z616
Time Cremation Started --L�
Time Cremation Completed
Type of Container 12-�
Remarks
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine view Crematorium, in
accordance with and subject to its Rules and Regulations to cremate
the remains of:
t^
(Name) (Sex)
(St_rs 4 a1 2- ,Pi
reet) (City) ' (StAte) (Zip Code)
who died on day of 6 LA1
at �,,� v Uvt S , P (c► ff( � J Z d'SIT
(Place) dress) '
Name and address of nearest living relative or name of person
au horizing cre ation:
U, ,� (L
(Name) (Address)
Relationship to the deceased' �-i
Name of Funeral Home �' I� ►� �vL l(7
IMPORTANT:
I e t t to the best of my knowledge, the deceased has or
as no pacema a 'n his or her body. (Circle One)
I certify that I have the full power and authorization to arrange
for the cremation of the remains and to direct the disposition of
the cremated remains, that any personal possessions have either
been removed or may be destroyed, and- agree to protect, defend and
save harmless Pine View Crematorium from any and all claims and
demands for loss or damages which may be made against them by
reason of or connected with the cremation of said remains as
directed, whether such claims or demands are or are not wholly
groundless, false or fraudulent.
( itness) (Addre )
<n 2 y
t
(Signature of Re tiv or Legal Rep. and Address)
Signed on this date: d